ALBANY - A grand jury investigating a fire that killed four mentally disabled residents at a state-run group home last March found no criminal wrongdoing, but cited numerous safety shortcomings that led to the tragedy.
The Hamilton County grand jury report released Tuesday details the events that led to the deaths of four of the nine residents of the Riverview Individual Residential Alternative home in the Adirondack village of Wells on March 21.
The report says three victims almost made it to safety but retreated into the burning building when the two staff members on duty were helping a resident who had fallen down. The report says that incident demonstrates the significant challenge in evacuating people who lack the skills to save themselves.
The residents also had physical disabilities, and only two were capable of leaving the building unassisted.
The grand jury recommends turning over inspection and code enforcement at all group homes for the developmentally disabled to the state Office of Fire Prevention and Control, saying the Office of Mental Retardation and Developmental Disabilities lacks needed expertise.
The report says the home had more fire safety features than many such homes in the state and met or exceeded all OMRDD residential requirements. However, because it was classified a residence for building codes and zoning, it was exempt from the more stringent New York State Fire Protection and Building Code for institutional occupancy. A fire alarm in the home worked properly.
The report also recommends further investigation by police agencies of alleged falsified records regarding fire training and drills at the Wells home.
Noting that ''at least one employee at Riverview was at least an occasional user of marijuana,'' the report recommends random drug testing for caretakers of the disabled and mandatory staff drug testing following an incident causing serious injury or death.
An OMRDD spokesman said the agency was reviewing the report Tuesday and had no immediate comment.
''The grand jury's report provides a tragic glimpse into the horrors that these people experienced in their final moments,'' said Donna Lieberman, executive director of the New York Civil Liberties Union.
She said two of the report's recommendations are particularly important: legislative action to eliminate all exemptions from the Uniform Fire Prevention and Building Code for facilities housing the developmentally disabled, and assigning code enforcement to fire safety professionals.
Five residents of the Wells group home were plaintiffs in the NYCLU's 1972 class action lawsuit on behalf of 6,000 residents of the notorious Willowbrook State School on Staten Island. The lawsuit led to the state moving the mentally disabled from large institutions to small group homes across the state.
The grand jury report calls for group homes to follow building code and fire safety standards appropriate to group care settings rather than private residences. If that were the case, the Wells home would have had an attic sprinkler system or fire retardant roof, among other safety features. It did have a functioning interior sprinkler system and fire doors.
The report says the fire started in a trash can on the back porch where staff members were known to smoke, but says it's impossible to say how the fire ignited. The flames spread quickly up the vinyl siding and into the attic. The nine-month-old, one-story home burned to the ground.
''New York state must learn from the tragedy of the Wells group home fire and act immediately to protect residents in the thousands of group homes like it across the state,'' Lieberman said.